CS Form No.
212
PERSONAL DATA SHEET
Revised 2017
WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the
person concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME KASHIM
NAME EXTENSION (JR., SR)
FIRST NAME MOHAMMAD RAZIF
MIDDLE NAME ALING
3. DATE OF BIRTH
16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy) 03/15/1994
by birth by naturalization
TONGUSONG, SITANGKAI, TAWI-TAWI
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female
6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS N/A N/A
Widowed Separated House/Block/Lot No. Street
Other/s:
N/A TONGUSONG
Subdivision/Village Barangay
7. HEIGHT (m) 1`75M SITANGKAI TAWI-TAWI
City/Municipality Province
8. WEIGHT (kg) 73KG ZIP CODE
9. BLOOD TYPE
18. PERMANENT ADDRESS N/A N/A
House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A TONGUSONG
Subdivision/Village Barangay
11. PAG-IBIG ID NO. N/A SITANGKAI TAWI-TAWI
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 7506
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 09058755152
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any)
[email protected]II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME KASIHM
NAME EXTENSION (JR., SR)
FIRST NAME NASHIR
MIDDLE NAME TANGKELLET
25. MOTHER'S MAIDEN NAME
SURNAME ALING
FIRST NAME LAHMA
MIDDLE NAME ARLOS (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST
SCHOLARSHIP/
26. PERIOD OF ATTENDANCE LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS
(Write in full) (Write in full) GRADUATED HONORS
EARNED
From To RECEIVED
(if not
ELEMENTARY TONGUSONG ELEMENTARY SCHOOL PRIMARY EDUCATION 2000 2006 GRADUATED 2006 VALIDICTORIAN
MSU-TCTO LARAP COMMUNITY HIGH SCHOOL WITH
SECONDARY HIGH SCHOOL 2007 2011 GRADUATED 2011 HONORS
VOCATIONAL / ELECTRICAL INSTALLATION AND
TESDA 2021 2021 2021 CERTIFICATE
TRADE COURSE MAINTENANCE NC II
MAHARDIKA INSTITUTE OF BACHELOR OF ELEMENTARY EDUCATION GRADUATED 2020 DIPLOMA
COLLEGE
TECHNOLOGY INC. 2016 2020
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 11/25/23
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity
PRC LET 82.8 OCT. 02, 2022 ZAMBOANGA, CITY N/A N/A
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
INCLUSIVE DATES SALARY/ JOB/
28.
PAY GRADE (if GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY (Format "00-0")/
APPOINTMENT
(Y/ N)
From To INCREMENT
N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 11/25/2023
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)
INCLUSIVE DATES OF Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS (mm/dd/yyyy)
NUMBER OF HOURS
Supervisory/ (Write in full)
(Write in full) From To Technical/etc)
ELECTRICAL INSTALLATION AND MAINTENANCE NC II 11/08/2021 12/06/2021 196.0 TECHNICAL TESDA
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 33. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)
COOKING N/A N/A
BASKETBALL ATHLETE MIT SCHOOL VARSITY
VOLLEYBALL N/A N/A
BASEBALL ATHLETE TONGUSONG, ELEM. SCHOOL ATHLETE
(Continue on separate sheet if necessary)
SIGNATURE DATE 11/25/2023
CS FORM 212 (Revised 2017), Page 3 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to
chief of bureau or office or to the person who has immediate supervision over you in the
Bureau or Department where you will be apppointed,
a. within the third degree? YES NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details:
35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:
b. Have you been criminally charged before any court? YES NO
If YES, give details:
Date Filed:
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, YES NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased out (abolition) in the public or private sector?
38. a. Have you ever been a candidate in a national or local election held within the last year YES NO
(except Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES NO
the last election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country? YES NO
If YES, give details (country):
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons
(RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following
a. items:
Are you a member of any indigenous group? YES NO
If YES, please specify: SAMA
b. Are you a person with disability? YES NO
If YES, please specify ID No:
c. Are you a solo parent? YES NO
If YES, please specify ID No:
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
NAME ADDRESS TEL. NO.
ID picture taken within
MUNICIPAL MAYOR OF SITANGKAI, the last 6 months
HON. MAYOR HJI, TIBLAN C. AHAJA TAWI-TAWI 9362302108 3.5 cm. X 4.5 cm
(passport size)
DR. HJA NURON S. ARAKANI DISTRICT SUPERVISOR, SITANGKAI,
TAWI-TAWI 9750497203 With full and handwritten
name tag and signature over
HEAD TEACHER, TONGUSONG
ISMAEL J. OMAR ELEM. SCHOOL 9091952979 printed name
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated
herein. I agree that any misrepresentation made in this document and its attachments shall cause the PHOTO
filing of administrative/criminal case/s against me.
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: PRC ID
ID/License/Passport No.: 1962928 Signature (Sign inside the box)
NOVEMBER 25, 2023
Date/Place of Issuance: 02/21/2023 ZAMBOANGA CITY
Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4
